Insomnia

Patient presents with complaints consistent with insomnia, characterized by difficulty initiating sleep, difficulty maintaining sleep, early morning awakenings, and non-restorative sleep.  These symptoms have been present for approximately [duration] and occur [frequency] per week.  Patient reports daytime impairment including fatigue, difficulty concentrating, irritability, and decreased performance at work/school.  Patient denies sleep apnea symptoms such as snoring or witnessed apneas.  Review of systems negative for restless legs syndrome.  Medical history significant for [relevant comorbidities, e.g., anxiety, depression, chronic pain].  Current medications include [list medications].  Social history reveals [caffeine intake, alcohol use, nicotine use, sleep hygiene practices].  Mental status exam reveals [mood, affect].  Physical exam unremarkable.  Differential diagnosis includes primary insomnia, insomnia due to a medical condition, insomnia due to a mental disorder, and substancemedication-induced insomnia.  Assessment:  Insomnia disorder, chronic.  Plan:  Discussed sleep hygiene recommendations including regular sleep schedule, creating a relaxing bedtime routine, and avoiding caffeine and alcohol before bed.  Cognitive behavioral therapy for insomnia (CBT-I) recommended.  Consider hypnotic medication for short-term symptomatic relief if CBT-I is unavailable or ineffective.  Follow-up in [timeframe] to assess treatment response and adjust plan as needed.  ICD-10 code: [appropriate ICD-10 code, e.g., G47.00, G47.01, F51.01].